Clin Endosc.  2023 Jan;56(1):92-99. 10.5946/ce.2022.020.

Endoscopic removal of common bile duct stones in nonagenarians: a tertiary centre experience

• Jalal M
• Khan A
• Ijaz S
• Gariballa M
• El-Sherif Y
• Al-Joudeh A

• KMID: 2538756
• DOI: http://doi.org/10.5946/ce.2022.020

Abstract

Background/Aims
There are few studies assessed the efficacy and mortality of endoscopic retrograde cholangiopancreatography (ERCP) for the removal of common bile duct (CBD) stones in the elderly aged ≥90 years. We aimed to assess the safety and efficacy of endoscopic removal of CBD stones in nonagenarians.
Methods
We retrospectively reviewed ERCP reports for CBD stone removal. The endoscopic and therapeutic outcomes were collected. The length of stay (LOS), the total number of adverse events, and mortality rate were compared between groups.
Results
A total of 125 nonagenarians were compared with 1,370 controls (65–89 years old individuals). The mean LOS for nonagenarians was significantly higher than in controls (13.6 days vs. 6.5 days). Completed intended treatment was similar in the nonagenarians and controls (89.8% and 89.5%, respectively). The overall complication rate did not differ between the groups. However, nonagenarians had a higher incidence of post-ERCP pneumonia (3.9%). None of the nonagenarians were readmitted to the hospital within 7 days. Four nonagenarians (3.2%) and 25 (1.8%) controls died within 30 days.
Conclusions
Advanced age alone did not affect the decision to perform the procedure. However, prompt diagnosis and treatment of post-ERCP pneumonia in nonagenarians could improve the outcomes and reduce mortality.

Keyword

Choledocholithiasis; Endoscopic retrograde cholangiopancreatography; Nonagenarians; Pneumonia

Reference

1. United Nations, Department of Economic and Social Affairs, Population Division. World population prospects 2019: highlights. New York (NY): United Nations;2019.

2. NHS. Hospital admissions hit record high as population ages. Leeds: NHS Digital‎;2016.

3. Harness JK, Strodel WE, Talsma SE. Symptomatic biliary tract disease in the elderly patient. Am Surg. 1986; 52:442–445.

4. Siegel JH, Kasmin FE. Biliary tract diseases in the elderly: management and outcomes. Gut. 1997; 41:433–435.

5. Sullivan DM, Hood TR, Griffen WO Jr. Biliary tract surgery in the elderly. Am J Surg. 1982; 143:218–220.

6. Williams E, Beckingham I, El Sayed G, et al. Updated guideline on the management of common bile duct stones (CBDS). Gut. 2017; 66:765–782.

7. Ashton CE, McNabb WR, Wilkinson ML, et al. Endoscopic retrograde cholangiopancreatography in elderly patients. Age Ageing. 1998; 27:683–688.

8. Ross SO, Forsmark CE. Pancreatic and biliary disorders in the elderly. Gastroenterol Clin North Am. 2001; 30:531–545, x.

9. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Scoping our practice (2004) [Internet]. London: NCEPOD;2004. [cited 2021 Dec 6]. Available from: https://www.ncepod.org.uk/2004sop.html.

10. Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2020; 52:127–149.

11. Sugiyama M, Atomi Y. Endoscopic sphincterotomy for bile duct stones in patients 90 years of age and older. Gastrointest Endosc. 2000; 52:187–191.

12. Rodríguez-González FJ, Naranjo-Rodríguez A, Mata-Tapia I, et al. ERCP in patients 90 years of age and older. Gastrointest Endosc. 2003; 58:220–225.

13. Mitchell RM, O’Connor F, Dickey W. Endoscopic retrograde cholangiopancreatography is safe and effective in patients 90 years of age and older. J Clin Gastroenterol. 2003; 36:72–74.

14. Hui CK, Liu CL, Lai KC, et al. Outcome of emergency ERCP for acute cholangitis in patients 90 years of age and older. Aliment Pharmacol Ther. 2004; 19:1153–1158.

15. Huguet JM, Sempere J, Bort I, et al. Complications of endoscopic retrograde cholangiopancreatography in patients aged more than 90 years old. Gastroenterol Hepatol. 2005; 28:263–266.

16. Cariani G, Di Marco M, Roda E, et al. Efficacy and safety of ERCP in patients 90 years of age and older. Gastrointest Endosc. 2006; 64:471–472.

17. Katsinelos P, Paroutoglou G, Kountouras J, et al. Efficacy and safety of therapeutic ERCP in patients 90 years of age and older. Gastrointest Endosc. 2006; 63:417–423.

18. Grönroos JM, Salminen P, Laine S, et al. Feasibility of ERCP procedures in patients 90 years of age and older. J Clin Gastroenterol. 2010; 44:227–228.

19. Hu L, Sun X, Hao J, et al. Long-term follow-up of therapeutic ERCP in 78 patients aged 90 years or older. Sci Rep. 2014; 4:4918.

20. Yun DY, Han J, Oh JS, et al. Is endoscopic retrograde cholangiopancreatography safe in patients 90 years of age and older? Gut Liver. 2014; 8:552–556.

21. Sobani ZA, Yunina D, Abbasi A, et al. Endoscopic retrograde cholangiopancreatography in nonagenarian patients: is it really safe? Clin Endosc. 2018; 51:375–380.

22. Saito H, Koga T, Sakaguchi M, et al. Safety and efficacy of endoscopic removal of common bile duct stones in elderly patients ≥90 years of age. Intern Med. 2019; 58:2125–2132.

23. Ogiwara S, Furihata M, Inami Y, et al. Does Endoscopic retrograde cholangiopancreatography carry higher risk for patients 90 years and older? A single-institution retrospective study. Med Sci Monit. 2020; 26:e928033.

24. Nakata B, Amano R, Kimura K, et al. Comparison of prognosis between patients of pancreatic head cancer with and without obstructive jaundice at diagnosis. Int J Surg. 2013; 11:344–349.

25. Waseem D, Tushar P. Intrahepatic, perihilar and distal cholangiocarcinoma: management and outcomes. Ann Hepatol. 2017; 16:133–139.

26. Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc. 2001; 54:425–434.

27. Finkelmeier F, Tal A, Ajouaou M, et al. ERCP in elderly patients: increased risk of sedation adverse events but low frequency of post-ERCP pancreatitis. Gastrointest Endosc. 2015; 82:1051–1059.

28. Schmitz-Moormann P, Himmelmann GW, Brandes JW, et al. Comparative radiological and morphological study of human pancreas. Pancreatitis like changes in postmortem ductograms and their morphological pattern. Possible implication for ERCP. Gut. 1985; 26:406–414.

29. Herzig KH, Purhonen AK, Rasanen KM, et al. Fecal pancreatic elastase-1 levels in older individuals without known gastrointestinal diseases or diabetes mellitus. BMC Geriatr. 2011; 11:4.

30. Friedrich K, Scholl SG, Beck S, et al. Respiratory complications in outpatient endoscopy with endoscopist-directed sedation. J Gastrointestin Liver Dis. 2014; 23:255–259.

31. Kollmann CM, Schmiegel W, Brechmann T. Gastrointestinal endoscopy under sedation is associated with pneumonia in older inpatients-results of a retrospective case-control study. United European Gastroenterol J. 2018; 6:382–390.

32. Fisher L, Fisher A, Thomson A. Cardiopulmonary complications of ERCP in older patients. Gastrointest Endosc. 2006; 63:948–955.

33. Navaneethan U, Njei B, Zhu X, et al. Safety of ERCP in patients with liver cirrhosis: a national database study. Endosc Int Open. 2017; 5:E303–E314.

34. Sawas T, Bazerbachi F, Haffar S, et al. End-stage renal disease is associated with increased post endoscopic retrograde cholangiopancreatography adverse events in hospitalized patients. World J Gastroenterol. 2018; 24:4691–4697.

35. Navaneethan U, Gutierrez NG, Jegadeesan R, et al. Factors predicting adverse short-term outcomes in patients with acute cholangitis undergoing ERCP: a single center experience. World J Gastrointest Endosc. 2014; 6:74–81.

36. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; 395:497–506.

37. Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020; 158:1518–1519.

38. Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013; 5:527–533.